Physiotherapy

Editorial Board

2012-06-01

Best tests/clinical findings for screening and diagnosis of patellofemoral pain syndrome: a systematic review

Chad Cook, Lance Mabry, Michael P. Reiman, Eric J. Hegedus — 2011-10-10

Abstract: Background: Diagnosis of patellofemoral pain syndrome (PFPS) is commonly performed using a myriad of clinical and imaging-based criteria.Objectives: The objective of this systematic literature review was to summarize the research on accuracy of individual clinical tests/findings for PFPS.Data sources: MEDLINE, ProQuest Nursing and Allied Health, Cochrane Trials, PEDro, and CINAHL.Study selection or eligibility criteria: PRISMA guidelines were followed for this review. To be considered for review, the study required: (1) a description of a clinical test or tests used for diagnosing PFPS (including a test that was combined with another finding such as patient history), (2) a report of the diagnostic accuracy of the measures (e.g., sensitivity and specificity), and (3) an acceptable reference standard for comparison.Study appraisal or synthesis methods: Quality Assessment of Studies of Diagnostic Accuracy (QUADAS) scores were completed on each selected article. Sensitivity, specificity, and negative and positive likelihood ratios (LR−/LR+) were calculated for each diagnostic test described.Results: The systematic search strategy and hand search revealed 704 potential articles, 9 of which met the criteria for this review; analysing a total of 22 PFPS clinical tests. After assessment using the QUADAS score, 1 of the 9 articles was of high quality. The tests with the highest reported diagnostic value were also associated with studies that had the lowest QUADAS values.Conclusion: A majority of the studies that have investigated diagnostic accuracy of clinical tests for PFPS demonstrate notable design or reporting biases, and at this stage, determining the best tests for diagnosis of PFPS is still difficult.

Exercise for rotator cuff tendinopathy: a systematic review

Chris Littlewood, Jon Ashton, Ken Chance-Larsen, Stephen May, Ben Sturrock — 2011-10-07

Abstract: Background: Shoulder pain due to rotator cuff tendinopathy is a common problem. Exercise is one intervention used to address this problem but conclusions from previous reviews have been mixed.Objective: To systematically review the effectiveness of exercise, incorporating loaded exercise (against gravity or resistance), for rotator cuff tendinopathy.Data sources: An electronic search of AMED, CiNAHL, Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, PEDro and SPORTDiscus was undertaken from their inception to November 2010 and supplemented by hand searching related articles and contact with topic experts.Study eligibility criteria: Randomised controlled trials evaluating the effectiveness of exercise, incorporating loaded exercise, in participants with rotator cuff tendinopathy.Study appraisal and synthesis methods: Included studies were appraised for risk of bias using the tool developed by the Cochrane Back review Group. Due to heterogeneity of studies, a narrative synthesis was undertaken based upon levels of evidence.Results: Five articles detailing four studies were included, all of which were regarded as presenting a low risk of bias. Overall, the literature was supportive of the use of exercise in terms of pain and functional disability.Limitations: The results should be regarded with some degree of caution due to limitations associated with the studies including lack of blinding, no intervention control groups and limitations of the outcome measures used.Conclusion and implications of key findings: The available literature is supportive of the use of exercise but due to the paucity of research and associated limitations further study is indicated.

Integrating physical and psychological approaches to treatment in low back pain: the development and content of the STarT Back trial's ‘high-risk’ intervention (StarT Back; ISRCTN 37113406)

C.J. Main, G. Sowden, J.C. Hill, P.J. Watson, E.M. Hay — 2011-06-13

Abstract: A new randomised controlled trial of intervention in low back pain has been described recently. In this trial, a screening and targeted approach was found to be more effective and cost-effective than current best practice. Nested within the intervention arm were three different interventions targeting patients identified as ‘low’, ‘medium’ or ‘high’ risk dependent on the presence of (mainly) psychosocial risk factors. In this paper, the development and content of the STarT Back trial's ‘high-risk’ intervention is described. It offers a systematic approach, termed ‘psychologically informed practice’, to the integration of physical and psychological approaches to treatment for the management of people with low back pain by physiotherapists. The term ‘disability’ is used to refer to self-reported pain-associated functional limitations, and ‘psychological’ is used to refer to the beliefs/expectations, emotional responses and behavioural responses associated with low back pain.

Evidence-based clinical guidelines for the diagnosis, assessment and physiotherapy management of contracted (frozen) shoulder: quick reference summary

2012-03-21

This is a summary of the key points and recommendations from the first version (v. 1) of Evidence-based clinical guidelines for the diagnosis, assessment and physiotherapy management of contracted (frozen) shoulder . This version encompasses diagnosis and assessment and, in terms of physiotherapy management, focuses on ‘standard physiotherapy’ (those interventions which could be practised by a graduate physiotherapist without additional training) although this has involved comparisons with other interventions, particularly steroid injections. Future versions will broaden the focus of physiotherapy management to incorporate other interventions within the scope of physiotherapy practice. The summary is not intended to stand alone. Readers are strongly advised to consult the full guidelines document, which expands upon the methodological processes and justifies the key points and recommendations.

Development and delivery of an exercise intervention for rheumatoid arthritis: Strengthening and stretching for rheumatoid arthritis of the hand (SARAH) trial

2011-06-06

Abstract: This paper describes the development and implementation of a hand exercise intervention for rheumatoid arthritis (RA) as part of a large multi-centred randomised controlled trial in a UK National Health Service (NHS) setting. Participants are eligible if diagnosed with RA according to American College of Rheumatology criteria, have a history of disease activity, functional deficit or impairment in the hand and/or wrist, and have been on a stable medication regime for at least 3 months. The intervention development was informed by the current evidence base, published guidelines, clinician and expert opinion, and a pilot study. The exercise programme targets known, potentially modifiable physical impairments of the hand with 5 exercise sessions and a home exercise component over a 12 week period. The intervention will be provided to 240 participants along with usual care. A further 240 will receive usual care only as part of the control arm. Specific details of the treatments delivered are described. [ISRCTN no: 89936343].

Evaluation of physiotherapists as primary assessors of patients with musculoskeletal disorders seeking primary health care

Maria Landén Ludvigsson, Paul Enthoven — 2011-07-04

Abstract: Objectives: To evaluate primary physiotherapist assessment and management of patients with musculoskeletal disorders in primary care, and to compare patient satisfaction with primary assessment by a physiotherapist or a general practitioner (GP).Design: An observational, retrospective cohort study reviewing medical records, and a separate consecutive non-randomised study of patient satisfaction.Setting: Primary healthcare centre.Participants: Four hundred and thirty-two patients with musculoskeletal disorders, primarily assessed by a physiotherapist. Fifty-one of these patients primarily assessed by a physiotherapist and 42 patients assessed by a GP answered a patient satisfaction questionnaire.Interventions: Primary assessment and management of patients with musculoskeletal disorders.Main outcome measures: Data from medical records within 3-month after the visit, and patient satisfaction questionnaire.Results: Eighty-five percent (367/432) of patients did not need to see a GP. Serious pathologies were found among the 6% (26/432) of patients who were referred to a GP by a physiotherapist, but no serious pathologies were found among the 9% (39/432) of patients who subsequently returned for a GP appointment for the same disorder. Patients assessed by a physiotherapist were more satisfied with the information received about their disorder and self-care than patients assessed by a GP. Patients also had higher confidence in the ability of physiotherapists to assess their disorder (P<0.002).Conclusion: Physiotherapists can be considered primary assessors of patients with musculoskeletal disorders in primary care as few patients needed additional assessment by a GP, patients with confirmed serious pathologies were identified by the physiotherapists, and patients were satisfied with assessment by a physiotherapist.

Assessment of the presence/absence of the palmaris longus muscle in different sports, and elite and non-elite sport populations

Craig Fowlie, Colin Fuller, Margaret K. Pratten — 2011-05-09

Abstract: Objectives: To investigate whether higher presence of the palmaris longus muscle is associated with sports that require hand grip.Design: Cross-sectional study.Participants: Six hundred and forty-two medical students, members of sports clubs and national athletes.Methods: Participants were invited to complete a questionnaire that assessed their main sport, elite or non-elite level of participation, and level of activity. The presence of the palmaris longus was assessed visually using a standardised test.Main outcome measures: Presence of the palmaris longus, type of hand grip required for the sport and the level of participation.Results: The presence of the palmaris longus was higher in elite athletes (21/22, 96%) than non-elite athletes (66/84, 79%; P=0.066) for sports that require a dominant-handed or two-handed cylindrical grip (18/22, 82% and 19/35, 54%, respectively; P=0.034). For both elite and non-elite athletes, the presence of the palmaris longus was higher in those participating in sustained grip sports (325/387, 84%) compared with sports that do not require a sustained grip (150/197, 76%; P=0.012).Conclusions: The palmaris longus may provide an advantage in certain types of sport that require hand grip, and for elite athletes participating in sports that require a dominant-handed or two-handed cylindrical hand grip. Orthopaedic specialists considering the use of the palmaris longus for a grafting procedure on an athlete should consider the level of participation and the type of hand grip required in the athlete's sport.

Interferential laser therapy in the treatment of shoulder pain and disability from musculoskeletal pathologies: a randomised comparative study

2011-05-30

Abstract: Background: Interference is an important feature of the waves. When two or more in phase light waves meet, a new and reinforced wave is generated. Shoulder pain is a common clinical problem and laser is one of the treatments frequently used to relieve it.Objective: To test the safety of interferential laser therapy generated by two independent low level lasers and compare its effectiveness with conventional single laser therapy in the reduction of shoulder musculoskeletal pain and associated disability.Design: Randomised and single-blind controlled clinical trial.Setting: Physiotherapy Unit and Rehabilitation Department of Ramon y Cajal University Hospital (Madrid).Participants: 200 patients with shoulder musculoskeletal pain were randomly assigned in two groups, 100 people each.Interventions: Group I, experimental (n=100) received interferential laser, placing two probes opposite each other over the shoulder joint. Group II, control (n=100) received conventional laser therapy, using a single probe along with a second inactive dummy probe. Lasers used were GaAlAs diode (810 nm, 100 mW), in continuous emission. Laser was applied in contact mode through ten sessions, on 5 shoulder points (7 Joules/point) per session.Main Outcome Measures: Visual Analogue Scale (VAS) score and Shoulder Pain Disability index (SPADI), recorded before and after laser treatment.Results: There were no differences between both groups in the reduction of pain, either assessed by VAS scale (median difference=0, 95% CI of the difference =-.6 to .5, p=0.81) or SPADI index (median difference = .4, 95% CI of the difference =-2.9 to 3.8, p=0.80), using the Mann-Whitney U-test. Comparison between the scores recorded before and after the treatment, within each group, showed significant differences for VAS during movement (median difference=3, 95% CI of the difference =2.07 to 4, p<0.001) and SPADI index (median difference=3.5, 95% CI of the difference =2.67 to 3.85, Wilcoxon test, p<0.001), for both groups.Conclusions: In this study, the application of two low level lasers in order to generate interference inside the irradiated tissue showed to be a safe therapy. Both interferential and conventional laser therapy reduced shoulder pain and disability. Nevertheless, differences between them were not detected. Future research in this field could include applying this technique with other laser parameters or application forms.

Does the application of an algorithm for non-invasive ventilation in chronic obstructive pulmonary disease improve the initiation process and patient outcomes?

Karen Ward, Hazel Horobin — 2011-07-18

Abstract: Objectives: Non-invasive ventilation (NIV) for acute hypercapnic respiratory failure in chronic obstructive pulmonary disease (COPD) has been shown to decrease endotracheal intubation and mortality; however, little guidance exists on NIV initiation. This study aimed to explore patient outcomes and the process of NIV initiation following the introduction of an algorithm.Design: Prospective, modified time-series study. Baseline measures were performed during the control period and repeated in the algorithm phase.Setting: Acute secondary care teaching hospital, wherever NIV was commenced (accident and emergency, medical assessment unit, thoracic medicine unit).Participants: Thirty-four patients with COPD and acute hypercapnic respiratory failure.Interventions: An algorithm was devised for use when initiating NIV, highlighting four aspects of care from the evidence base: synchronisation, tidal volume, oxygenation and comfort.Main outcome measures: Arterial pH value, Borg scale rating of breathlessness, and a staff questionnaire on the process of NIV initiation.Results: No significant difference was found in changes in pH or Borg score. However, three of the four aspects of care promoted by the algorithm were reported more frequently in the intervention phase. Increased assessment of tidal volume (5/17 cases in control phase, 95% confidence interval 0.05 to 0.54; 12/17 cases in algorithm phase, 95% confidence interval 0.46 to 0.95) reached statistical significance (P=0.038, Fisher's exact test).Conclusions: This study presents an algorithm to assist the application of NIV, and has demonstrated changes in practice following its introduction. It is proposed that the algorithm is considered for use within services that initiate NIV. Further work is required to explore the effects of staff education and the promotion of ownership.

Three-dimensional kinematic analysis of pelvic and lower extremity differences during trunk rotation in subjects with and without chronic low back pain

Ah Young Song, Hang Jin Jo, Paul S. Sung, Yoon Hyuk Kim — 2011-05-10

Abstract: Objective: To investigate three-dimensional angular changes of the pelvis and lower extremities during trunk axial rotation in subjects with and without chronic low back pain (LBP).Design: Repeated-measures design.Participants: Thirty volunteers participated in the study (15 with LBP, 15 without LBP). The mean age of the subjects was 44 (standard deviation 15.8) years (range 27 to 63 years).Main outcome measures: All participants were asked to perform five sets of axial trunk rotation activities with a bar in a standing position. The outcome measures included three-dimensional rotational angles of the pelvis and lower extremities (foot, calf and thigh).Results: The angular change of the pelvis in the sagittal plane differed between subjects with and without LBP (P=0.03). There were no significant differences in angular changes of the lower extremities in the frontal and transverse planes between groups.Conclusions: The angular change of the pelvis in the sagittal plane differed significantly between groups. Further research is needed to investigate the three-dimensional characteristics of biomechanical and neuromuscular aspects in subjects with LBP.

Contemporary undergraduate physiotherapy education in terms of physical activity and exercise prescription: practice tutors’ knowledge, attitudes and beliefs

Grainne O’Donoghue, Tara Cusack, Catherine Doody — 2011-10-24

Abstract: Objectives: Practice tutors’ evaluation to (i) establish current physical activity and exercise promotion and prescription curriculum content and (ii) their knowledge, attitudes and beliefs concerning physical activity and exercise prescription in clinical education, in terms of contemporary and emerging health trends and priorities.Design: A cross sectional survey employing a questionnaire and focus groups.Participants: All practice tutors delivering physiotherapy undergraduate education in four physiotherapy schools in Ireland (n=38) were invited to participate. Thirty participated giving a response rate of 79%.Methods: Two methods of data collection were employed. Clinical content questionnaires were administered, the results of which informed follow-up focus groups. Focus group transcriptions were analysed using the ‘Framework Analysis’ method.Results: 66% of practice tutors were unhappy with their own knowledge and felt they required further training in the following areas: strategies for changing physical activity behaviour; exercise promotion and prescription for public health; exercise prescription for lifestyle related disease. Main themes emerging from the focus groups were (i) perceptions of the physiotherapist's role, (ii) perceptions of the practice tutor's role and (iii) facilitators and barriers to change.Conclusion: In terms of physical activity and exercise prescription education, practice tutors identified a need for further education to improve their knowledge base. However, their attitudes and beliefs relating to physiotherapists’ and educators’ role in terms of teaching contemporary and emerging health trends and priorities were mixed. Results of this study provide useful data to inform future physiotherapy curricula development in terms of physical activity and exercise content.

Measurement properties of a hand-held inclinometer during straight leg raise neurodynamic testing

Benjamin S. Boyd — 2011-06-06

Abstract: Objectives: The most common lower quarter neurodynamic test is the straight leg raise (SLR) test. Quantification of limb motion during SLR testing should utilize reliable and valid measurement tools that are highly sensitive to change. The purpose of this study was to determine the psychometric properties of a hand-held inclinometer commonly utilized during SLR testing.Design: Cross-sectional measurement, intra-rater reliability and validity study.Setting: Research laboratory.Participants: Twenty individuals without pain in their low back or extremities and no history of nerve injury participated in the study.Main outcome measures: Two repetitions of the SLR were performed in each limb in two ankle positions (plantar flexion and dorsiflexion). A digital inclinometer and digital goniometer were utilized as the comparisons for range of motion measurements.Results: Intra-rater reliability for the hand-held inclinometer during SLR testing was excellent (ICCs, 0.95 to 0.98). The standard error of measurement was between 0.54° and 1.22° and the minimal detectable change was between 1.50° and 3.41°. Construct validity revealed hand-held inclinometer measurements were highly correlated with both the digital inclinometer and digital goniometer measures. The mean difference scores between hand-held inclinometer and digital inclinometer (∼1.5°) and digital goniometer (∼10°) suggest that the hand-held inclinometer better matches the construct measured by the digital inclinometer (limb elevation angle) compared to the digital goniometer (hip flexion angle).Conclusions: The hand-held inclinometer is a valid method for measuring limb elevation angle during the SLR neurodynamic test in a research setting. The hand-held inclinometer has high reliability and low minimal detectable change when used in healthy individuals.

Patient-centered research

Amos Peter Lee — 2012-01-19

I wish to commend the authors of the article, ‘User experiences, preferences and choices relating to functional electrical stimulation and ankle foot orthoses for foot-drop after stroke’ , for taking a somewhat different route of research compared with the norm. Their qualitative study was refreshing, in that it focused on the patient's experience of orthotic usage and documented what the patient perceived as most important and helpful. A current issue in physiotherapy is the low level of patient compliance towards professional advice such as completing a home exercise program . This lack of compliance has been estimated to be as high as 70% and has significant implications for the effectiveness of physiotherapy interventions, healthcare costs and patient outcomes. Thus, conducting research focused on the patient's point of view may help clinicians prescribe treatments that are better tolerated, and in that way, lead to more meaningful outcomes. In the case of stroke patients with lower limb weakness and foot drop, it may enable them to make a more informed decision regarding their management of the condition.